Working with mental health problems: clients’ experiences of IPS, vocational rehabilitation and employment

ORIGINAL PAPER

Working with mental health problems: clients’ experiencesof IPS, vocational rehabilitation and employment

Marsha Koletsi Æ Astrid Niersman Æ Jooske T. van Busschbach Æ Jocelyn Catty ÆThomas Becker Æ Tom Burns Æ Angelo Fioritti Æ Rana Kalkan Æ Christoph Lauber ÆWulf Rossler Æ Toma Tomov Æ Durk Wiersma Æ for the EQOLISE Group

Received: 15 October 2008 / Accepted: 18 February 2009 / Published online: 12 March 2009

� Springer-Verlag 2009

Abstract

Background Although the effectiveness of individual

placement and support (IPS) has been well established,

little is known about clients’ perceptions of the model

compared to usual vocational rehabilitation, nor about their

experiences of searching for and returning to work with

this kind of support. This qualitative study aimed to

explore clients’ views of the difficulties of obtaining and

maintaining employment, their experiences of the support

received from their IPS or Vocational Service workers and

the perceived impact of work on clients’ lives.

Method Semi-structured interviews were conducted with

48 people with psychotic disorders participating in a six-

centre international randomised controlled trial of IPS

compared to usual vocational rehabilitation. To assess their

experiences of the services and the perceived effects of

working, two IPS and two Vocational Service clients at

each centre who had found work during the study period

were interviewed, along with two IPS and two Vocational

Service clients at each centre who had not.

Results IPS clients reported having received more help

seeking and maintaining employment, whereas Vocational

Service clients reported having received more help in

finding sheltered employment or placements. Clients who

had worked associated this with financial stability,

improved social lives, increased self-esteem, integration

into society and amelioration of their symptoms, as well as

reduced feelings of boredom and isolation, but also

reported increased levels of stress. IPS clients as well as

Vocational Service ones reported not receiving enough

The EQOLISE Group: Tom Burns, Jocelyn Catty, Connie Geyer,

Marsha Koletsi, Pascale Lissouba, Miles Rinaldi, Sarah White

(London), Thomas Becker, Ulrike Ehiosun, Rana Kalkan, Reinhold

Kilian (Ulm), Angelo Fioritti, Denise Manchisi (Rimini), Astrid

Niersman, Jooske T. van Busschbach, Durk Wiersma (Groningen),

Christoph Lauber, Wulf Rossler, Ingeborg Warnke (Zurich), Dimitar

Germanov, Toma Tomov (Sofia), Adelina Comas, Claire Curran,

Martin Knapp, Anita Patel (LSE).

M. Koletsi � J. Catty

Division of Mental Health, St. George’s, University of London,

London, UK

A. Niersman � J. T. van Busschbach (&) � D. Wiersma

University Medical Centre, University of Groningen,

Groningen, The Netherlands

e-mail: [email protected]

T. Becker � R. Kalkan

Department of Psychiatry II, University of Ulm,

BKH Gunzburg, Gunzburg, Germany

T. Burns

University Department of Psychiatry,

Warneford Hospital, Oxford, UK

e-mail: [email protected]

A. Fioritti

Programma Salute Mentale, Azienda USL Rimini,

Rimini, Italy

C. Lauber � W. Rossler

Psychiatric University Hospital,

University of Liverpool, Zurich, Switzerland

T. Tomov

Bulgarian Institute of Human Relations, Sofia, Bulgaria

123

Soc Psychiat Epidemiol (2009) 44:961–970

DOI 10.1007/s00127-009-0017-5

follow-up support, despite this being proposed as a key

feature of the model.

Conclusion Findings from the in-depth interviews reflect

differences in service models that have also been tested

quantitatively but further work in disaggregating the IPS

model and assessing the impact of each component would

be valuable.

Keywords Severe mental illness � Employment �Vocational rehabilitation � Qualitative assessment

Background

The importance of employment to people with schizo-

phrenia and other severe mental illnesses (SMI) has been

clearly demonstrated [12, 18, 20, 27], although employ-

ment rates are low: between 10 and 20% for those with

schizophrenia in Europe [17]. Conversely, unemployment,

along with social isolation, has been found to be associated

with a risk of psychosis [22]. Low employment rates of

those with SMI are understood to reflect a combination of

social and economic pressures, labour market conditions

and psychological and social barriers (such as stigma

among potential employers [26]) along with lack of pro-

fessional support [17]. Studies of supported employment

over the last 10 years have investigated the effectiveness of

such support.

Evidence for the individual placement and support (IPS)

model of supported employment has been provided in the

US by more than eight randomised controlled trials (RCTs)

and three quasi-experimental studies [5], showing that

people with SMI who wish to work can be successfully

integrated into the labour market [6]. The effectiveness of

IPS has been recently demonstrated in Europe by an RCT

in six European centres [8], which showed IPS doubling

the access to work of people with SMI. Moreover, working

was associated with better clinical and social functioning

and with a slight decrease in depression [9]. Long-term

follow-up of sub-samples of supported employment clients

has found all to have had some subsequent employment,

the majority (71%) for more than half of the 8–10 year

follow-up period [3].

Although the effectiveness of IPS has been well estab-

lished, little is known about clients’ perceptions of the

model compared to usual vocational rehabilitation, nor

about their experiences of searching for and returning to

work with this kind of support. IPS clients have been found

to report higher levels of job satisfaction and have longer

job tenures if they obtained jobs matching their pre-

employment preferences [19]. Maintaining a job has also

been found to be more difficult than acquiring one, beset by

interpersonal problems, problems related to their mental

illness, dissatisfaction with the job and poor work quality

[2]. Given the impairments of social functioning associated

with SMI, social interactions in the workplace are con-

sidered a valued outcome in rehabilitation settings [16],

although interpersonal relationships there may be sources

of either support or stress [7]. The increase in subjective

quality of life for people with SMI when obtaining a job

has been shown to be mediated by supportive relations with

colleagues [23]. Little is known, however, about the impact

of vocational support on social problems in the workplace.

In the general population, several motivating factors for

working have been identified, such as interesting work,

good wages, appreciation and job security [15]. Most

people with SMI want to work and see finding employment

as an important step towards recovery [12, 21]. Yet people

with SMI have reported both benefits and drawbacks

from being employed: work is seen as a way to get well but

also as a source of stress, and the time spent at work is

experienced as positive when the tasks performed are

meaningful and purposeful but some feel that it keeps them

from other more valued activities [14]. Conversely,

employment may lead to increased self-esteem and may

ameliorate symptoms such as hearing voices because of the

focus on work tasks and daily structure [25]. Moreover,

doubts about the ability to work, possible discrimination

and a lack of support from professionals may lead to

reluctance to enter the labour market [18]. The present

study aimed to explore through semi-structured interviews

clients’ experiences of finding work and staying employed,

along with the influence of IPS and regular vocational

services on these processes.

Objectives

1. To explore clients’ views of the difficulties of

obtaining and maintaining employment.

2. To explore clients’ experiences of the support received

from their IPS or Vocational Service workers.

3. To explore the perceived impact of work on clients’

lives.

Method

Semi-structured interviews were conducted during the last

6-month period of an international RCT comparing IPS

to standard vocational rehabilitation. Inclusion criteria for

the main study were: diagnosis of SMI (psychotic illness

including bipolar disorder), aged 18 to retirement age,

having been ill and having had major role dysfunction for

at least two years, living in the community at baseline, not

in competitive employment in the preceding year and

962 Soc Psychiat Epidemiol (2009) 44:961–970

123

expressing the desire to enter competitive employment (on

the open market) [8]. For the present study, eight semi-

structured interviews were conducted in each of the six

study sites (London, Ulm-Gunzburg, Rimini, Zurich,

Groningen, Sofia), totalling 48 interviews. The sampling

was purposive, selecting four IPS and four Vocational

Service clients at each centre: two in each group having

worked during the follow-up period and two not having

worked.

The interview consisted of 25 open and 73 closed

questions in a total of seven sections: job history, work

assistance, perceived barriers, benefits, normative aspects

of work, perceived effects of working and disclosure of

mental illness at work [24]. The open questions were

designed to provide an overview of clients’ opinions of the

service they received and the impact of work on their lives,

while the closed questions facilitated direct comparisons

between groups (IPS versus Vocational Service and

working versus non-working groups). These closed ques-

tions also provided an overview of the assistance provided

by the IPS or Vocational (control) Service in obtaining and

maintaining employment.

Quantitative data from the semi-structured interviews

were analysed descriptively to provide a context for the

qualitative material. The qualitative material was translated

into English by each interviewer, and then divided and

coded separately by two researchers (MK and AN). The

iterative process of coding and comparing was done using

the digital transcripts. The total amount of text was rela-

tively small and easy to access so no tailor-made database

was required. The main ideas expressed were coded, after

which each transcript was re-read and potential themes

were identified and recorded. The themes were then

re-examined by the original six interviewers and consensus

was reached. Commonalities and differences in themes

between the four groups were identified and a set of

quotations was chosen to represent the main themes.

Results

Clients’ demographic characteristics and working

patterns

Of the 48 participants, 29 had diagnoses of schizophrenia, 15

bipolar affective disorder and four other psychotic diagnoses.

Over half (n = 29) had worked for more than a month during

the 5 years prior to baseline (Table 1). For the 24 clients who

had worked during the 18-month follow-up period, the

average number of jobs that they held during this time was

1.4 and the mean duration of employment 232 days.

The IPS clients interviewed had obtained more jobs and

had longer job tenure than Vocational Service clients. Most

IPS clients who had worked (n = 8) had done so every day

of the week, whereas most Vocational Service clients had

worked for a few days per week. Their patterns of working

were similar, however, in hours per day, with nine IPS and

eight Vocational Service clients having worked only a

few hours per day. Similar numbers in each group had been

given a trial period in the job. IPS clients had been

employed for more days and fewer of them reported having

received less money because of their psychiatric history.

The findings below are discussed in terms of the main

themes of the qualitative data. References to ‘quantitative

data’ below are to data provided through the closed ques-

tions from the semi-structured interview.

Perceived barriers

Clients from all groups reported similar problems finding

jobs, although the Vocational Service clients who had not

worked reported the most barriers. Such barriers comprised

both personal and external factors (Table 2).

Most clients perceived their symptoms to have been a

significant barrier to finding work: ‘For my work I have to

keep up-to-date [on developments in the field], but study-

ing is a problem. I hear voices in my head and that makes it

difficult to concentrate’. Those who had worked (from

both services) believed their history of mental illness and

stigma to have been the greatest barrier: ‘Society does not

understand schizophrenia’. Age was also a significant

barrier, as they believed it to be ‘the first question asked by

every prospective employer’ and they associated ‘being

older’ with having ‘fewer chances of finding a job’.

Table 1 Semi-structured interview: clients’ characteristics (n = 48)

Male 27 No. of psychiatric admissions

Age group 0 7

18–33 15 1–5 35

34–49 18 6–10 4

50–57 15 11? 2

Marital status Age of 1st contact with services

Single or divorced 39 Below 18 4

Married 9 18–25 18

Highest completed education 26–35 11

Primary or less 3 34–41 9

Secondary 20 42–57 6

Tertiary 22 Diagnosis

Other general education 3 Schizophrenia 29

Living situation Bipolar 15

Living alone 19 Other 4

Living with family

Living with others

23

6

Work history in 5 yearspre-baseline

\1 month 29

[1 month 19

Soc Psychiat Epidemiol (2009) 44:961–970 963

123

Twenty-eight clients (14 in each service) had had no

previous work experience. Only the IPS clients considered

this a significant barrier. One explained: ‘I have not worked

for 10 years, so I lack recent work experience. As a result,

employers have less confidence in me’. Clients also found

their own lack of motivation an important drawback in

looking for work: ‘It’s a big step to work again after so

many years—I’m used to my situation and I’ve accepted

it’.

Clients believed that unemployment rates had been very

high during the study period (2003–2005), providing a

major barrier to employment: ‘My problem finding a job is

that there are few jobs available at the moment’. They

described themselves as being ‘unfamiliar’ with the dif-

ferent phases involved in job-searching and said there had

been a great degree of ‘uncertainty’ and of ‘not knowing

where to look for a job’. These results were complemented

by the quantitative data, as the majority (n = 35) stated

that the restricted market had been a major drawback.

Clients also had trouble finding jobs to match their

interests: ‘I was offered jobs by my Vocational Worker that

either I did not like or I did not feel able to do. I wanted to

work as an electrician and was offered to work as a shop

assistant instead’. Out of all 48 clients, one in three saw the

difficulty of finding a job they preferred as a major barrier

to entering the labour market.

Most clients (n = 30) in both services were worried that

they would not be able to do their job correctly or would

have problems with their colleagues. This fear was seen as

a significant barrier. One explained: ‘I was afraid of having

difficulties with my colleagues or my employer. This had

already happened in my previous job a few years ago and

as a result I felt depressed’. This was confirmed by the

quantitative data, with more IPS clients (n = 13) than

Vocational Service clients (n = 8) being concerned about

having problems with colleagues.

Clients from both services were also fearful that they

would be perceived only as psychiatric patients and said

this had had a negative effect when they were looking for

work. The quantitative data, however, showed that most

clients (n = 39) had not experienced stigma during the

study.

The job search itself was also considered to have been

‘lengthy’, a ‘complicated procedure’ and a ‘time-consum-

ing process’. Clients had had difficulties in preparing a

curriculum vitae and knowing how to fill in application

forms. They attributed their difficulties to lack of career

advice.

Half the clients, whether they had worked or not,

believed that the most important factor in finding work was

being pro-active. Some mentioned the importance of

looking for jobs that interested them. Others mentioned

perseverance and awareness of one’s abilities and limita-

tions: ‘It is important to know what you want. If you know

that, then get on with it without thinking about it for a long

time. The most important things are to know what you

want and also what are you able to do’. They also con-

sidered it important to feel well enough to go to work: ‘If

you feel well and able to do a job, you will also feel better,

your days will be full, and you will feel satisfied with

yourself. Work gives you the courage to go on living. You

feel like you have done your duty’.

Help finding work

Clients’ experiences of help in seeking and maintaining

work varied according to the service (Table 3). Twelve IPS

clients reported being helped to search for jobs, unlike the

Vocational Service clients (n = 2). One IPS client

explained: ‘She (the IPS Worker) knew about the field of

work. She put a little pressure on me about why I should

work at this place. She organised meetings and took the

role of mediator and always asked me how I was coping

with my job’. Another IPS client explained: ‘She found

jobs for me, calmed me down and gave me helpful advice

about how to get on with my boss’.

This was reinforced by the quantitative data, which

showed more IPS clients (n = 20) reporting that they

received help in getting a job than Vocational Service

Table 2 Semi-structured interview: barriers to getting a job

Personal factors External factors

Mental illness (n = 11)

Age (n = 6)

Lack of previous working

experience/qualifications

(n = 5)

Lack of confidence/motivation

(n = 5)

Duration out of work (n = 3)

Restricted job market, unfamiliarity,

not knowing where to look

(n = 19)

No jobs to match interests (n = 8)

Bad working conditions (n = 5)

Disclosure of mental illness/stigma

(n = 4)

Complicated procedures (e.g. job

search a time-consuming process)

(n = 5)

No barriers reported (n = 3)

Table 3 Semi-structured interview: help received by IPS/Vocational

Worker

Help finding a job Help maintaining a job

Job search (n = 14) No help (n = 11)

Job interview/filling in

application forms (n = 10)

Advice during the job

(n = 5)

Preparing clients for work (n = 7) Job coaching (n = 4)

Advice on benefits (n = 3) Personal support (n = 4)

No help (n = 9)

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123

clients (n = 4), who mostly found their jobs by themselves

(through the internet, job agencies, or newspapers). Almost

all the IPS clients (n = 23) reported being encouraged by

the IPS Worker to try working, whereas most Vocational

Service clients (n = 19) said they had not received this sort

of encouragement.

More IPS clients (n = 7 compared to n = 3 for Voca-

tional Service clients) also said that their IPS Worker

helped them complete job application forms. One stated: ‘I

wrote an application letter and got the job. Maybe I found

the job because of the IPS Worker; I probably took the

initiative to write this letter because of her motivation’.

Similarly, more IPS than Vocational Service clients (9

compared to 4) were helped practise for interviews, while

IPS clients were also more likely to have been taken to job

interviews (6 compared to 2). IPS clients also received

more guidance and advice from their IPS Worker on their

benefits, 11 reporting this compared to three Vocational

Service clients. Some IPS clients were also helped to

prepare for work (by increasing self-esteem, having real-

istic goals, working on their fears). One explained: ‘My

IPS Worker was not prejudiced towards me; she was kind

and able to calm me down. She found me a job, was

hopeful and motivating’.

By contrast, nine clients, eight of whom were with the

Vocational Service, stated that they did not receive any

form of help when looking for work. Vocational Service

clients received more training than IPS clients, however.

This training might be done in a sheltered workplace, for

instance through a training course. Five IPS and 10

Vocational Service clients received extra training and

almost all found it very helpful.

About half of the Vocational Service clients who had

worked had taken jobs that were not their preference: ‘I

saw the job in the newspaper. It was a job that was avail-

able. It was not a job I had ever dreamed about’. By

contrast, almost all the IPS clients said that the IPS Worker

took their preferences into account and chose jobs

according to their needs. Nevertheless, some had found

jobs that were not their first choice: ‘I was driven to do this

job because of my situation… I cannot use my skills and

qualifications in my job’.

Lack of help looking for suitable jobs was the most

widely reported factor among those who had not found

them (reported by 15 Vocational Service and 4 IPS clients).

Vocational Service clients stated that they received some

help in finding sheltered employment, training or place-

ment, but that overall their Vocational Worker had not

been in tune with their needs. One client explained: ‘The

service was interested in moving people into sheltered

work or placements regardless of their interests and qual-

ifications; their aim was only to improve their own

records’. Another stated: ‘I only got help in finding

sheltered work for work experience. I did not want to work

with other psychiatric patients and also I was not happy

because it was an unpaid job’. They also felt that there was

a lack of flexibility in the service and that they would have

liked a more individualised approach. As one client

explained: ‘The help only involved sheltered employment.

My Vocational Worker did not look for a job in the open

market. I expected openness and commitment from my

Vocational Worker’. Some reported negative experiences,

such as feeling that there was no belief in their abilities or

readiness for work: ‘My Vocational Worker was not of any

help. He was discouraging and said that I was not able to

work because I had unrealistic ideas’.

Some IPS clients also reported lacking support from

their IPS Worker. Those who had not succeeded in finding

a job were most likely to report having lacked help,

especially in looking for jobs, the IPS Worker not knowing

their field of work or the IPS Worker not having a network

of appropriate employers to draw on. IPS clients also reported

lacking advice on benefits from their IPS Worker and

expressed a desire for more frequent contact and support

while at work: ‘I would have liked more support and more

regular contact while at work to avoid being sick’.

Twenty clients (12 IPS and 8 Vocational Service)

received additional help from others in finding a job,

mostly from mental health professionals or GPs, as well as

family and friends. This was mainly focused on providing

general support and motivation.

Help with maintaining employment

Half the clients who had worked, regardless of service,

experienced problems keeping their jobs (Table 4). The

presence of psychiatric symptoms was the most commonly

reported factor. One client explained: ‘My symptoms came

back and I started hearing voices again. I was getting

paranoid; I thought people were talking behind my back, so

I felt uncomfortable with work’. Seven clients reported

difficulties fulfilling their job requirements, such as being

at work on time or keeping the same pace as their col-

leagues. One client from the Vocational Service, who had

lost the one job she obtained during the follow-up period,

explained: ‘I made too many mistakes and I could not focus

Table 4 Semi-structured interview: barriers to maintaining a job

Personal factors External factors

Psychiatric problems

(n = 9)

Problems with employer/

colleagues(n = 4)

Unable to fulfil job

requirements (n = 5)

Pressure/stress at work (n = 4)

Being in fixed-term contract

(n = 3)

Soc Psychiat Epidemiol (2009) 44:961–970 965

123

on my tasks. I was also too slow and it did not improve. In

my life I have lost eight jobs for these reasons’.

The majority of the clients were worried that they would

not do their job correctly. Vocational Service clients

experienced more difficulties than IPS clients in work-

related areas, however. Some were worried that they would

have problems with their colleagues. One explained: ‘I had

problems with my colleagues, they were harassing me’.

Others had problems with their employers: ‘I had problems

with my boss; she did not allow me to take any days off or

even take sick leave’. They associated work with increased

levels of stress: ‘I had to be very fast and precise and that

was difficult for me’. Nevertheless, eight of the working

clients reported having had no difficulties maintaining their

jobs. One client stated: ‘I used to be ill a bit, but took some

time off, and my employers showed tolerance and under-

standing so I was allowed to return to work after my sick

leave’.

Although more IPS than Vocational Service clients were

helped find a job by their IPS or Vocational Worker, there

were few differences between them in the help they

received in maintaining their jobs. Only two IPS clients

had been visited by their IPS Worker at work, while none

of the Vocational Service clients had. Moreover, most

clients who had worked had not been helped by the IPS or

Vocational Worker to learn the tasks involved and none

had been taken to work by them. Four IPS clients, however,

reported having been helped to get on better with their

colleagues, while no Vocational Service clients reported

this. Six IPS and two Vocational clients reported having

talked to the worker about work-related stress.

Incentives to continue working

Almost half of the clients, irrespective of service, found the

financial reward the biggest incentive to continue working.

One explained: ‘I was driven by my lack of money’.

Financial need drove some clients to take jobs they did not

like: ‘I hated the job and the working environment but

needed the money’.

Clients reported wanting to work because this would

give them a daily structure, the means to gain indepen-

dence, stability and satisfaction in themselves. Work was

perceived as offering them a new identity (‘I felt that I had

a new identity and was needed by others’) and a sense of

normality and acceptance: ‘I feel comfortable and accepted

by others. Others take me seriously and it is nice to feel

useful to others’. When they were asked about the things

that had helped them find a job or to keep working, one of

the factors most cited was the ‘belief that I can make it’ and

an overall trust in themselves.

Some clients felt that their working conditions had helped

them maintain their employment: a good atmosphere, a

variety of duties or their schedule. One said: ‘I only work

six hours a week, this makes it easier to keep my job’, while

another said, ‘I have a variety of duties in my job and that

helps’. Half the working clients felt that the social environ-

ment was important. Co-workers were a problem for some,

while for others their co-workers helped them to keep

working. More clients (especially from the IPS Service) had

support from colleagues than experienced problems with

them: ‘My colleagues helped me to keep working. The social

surrounding is more important than the kind of work I am

doing’.

Half the clients had their medication adjusted during the

study and most of these considered the adjustment as

having had a positive effect: ‘I started using tablets instead

of depot… I feel clearer in my head’.

Benefits were important to all the clients when they

started working. Half of the clients who had worked

reported that their benefits had stayed the same. These

clients earned a small wage on top of their benefits. For

others, their extra income was deducted from their benefits

and because of that some found that their income stayed the

same: ‘Because of my illness, I am not able to work full-

time, so I will always stay in the benefit system. Financially

nothing improved because my wage was deducted from my

benefits’. Only a few of the working clients had actually

replaced their benefits with salary. Overall, the expecta-

tions of the non-working clients about the likely impact on

their benefits—the majority not being afraid of losing

benefits—seems to have corresponded with the reality as

reported by the working clients.

Perceived effects of working

Clients expressed positive and negative views about the

impact work had on them (Table 5), which did not differ

between the IPS and Vocational Service groups.

Table 5 Semi-structured interview: impact of work

Positive factors Negative factors

Financial stability (n = 28) Stress/tiredness (n = 20)

Improved of social life

(n = 27)

Conflicts with colleague/

employer (n = 10)

Increased self-esteem/

satisfaction (n = 16)

Lack of time

(n = 7)

Integration into society/

acceptance (n = 15)

Lack of control/flexibility

(n = 8)

Self-improvement (n = 8) Restructure of time (n = 5)

Coping strategy/distraction

(n = 6)

Improved of illness (n = 5)

Reduced boredom/loneliness

(n = 5)

966 Soc Psychiat Epidemiol (2009) 44:961–970

123

Positive factors

Work positively affected clients’ financial status and

contributed to their obtaining ‘stability’ and ‘financial

independence’, ‘economic status’ and the choice of ‘a better

way of living’. Increased social contact was another benefit.

Through their jobs, clients felt less isolated and met more

people. One stated: ‘I got to socialise more, got to know

more people and increased my social contacts’. Most clients

felt lonely during the follow-up period, but eight felt less

lonely after starting working, although two clients felt more

lonely and isolated.

Work also had a positive impact on clients’ personalities

and feelings about their lives. Eight IPS and nine Voca-

tional Service clients stated that work made them feel

happier and more satisfied with themselves. Work func-

tioned as a distraction from thinking about their illness and

as a coping mechanism and gave them a sense of being

needed: ‘People do not think about their illness while at

work. They feel needed by others and satisfied with the

work and the results’. Work was further perceived as a

means to get ‘acceptance’, a ‘purpose in life’, a ‘sense of

belonging’ and ‘re-integration into society’: ‘I’m more

independent both economically and as a person. I’m

healthier and more integrated into working society’. They

also gained more independence and stability: ‘I feel more

autonomous and more stable since I started working’.

As a result, clients felt part of society and developed

more positive views of themselves. The majority (n = 18)

stated that they felt more confident after starting working

and also more hopeful about the future: ‘Your self-confi-

dence improves as you feel more satisfied, you can achieve

something and also earn money’; ‘I feel more confident and

more satisfied with myself, as I can contribute to society. I

never wanted to use the system, but rather wanted to be a

part of and be an active member of society’. Clients also

became more aware of their needs and limitations and saw

work as a means to obtain self-realisation: ‘My view of

myself has changed seriously for the better. I’m more

aware of the strengths and weaknesses of my character’.

Work also offered clients the opportunity to feel ‘more

equal’ and accepted by other people: ‘I feel more accepted

and found out that I can perform better than I thought and

overall my interest for work and things in general is

enhanced’.

Some clients also stated that work had had a positive

effect on their mental health: ‘Work helped me feel better

physically and psychologically’. Nine IPS clients reported

that their symptoms decreased after they started working,

whereas seven Vocational Service clients said that their

symptoms remained the same, with only four saying they

decreased. Most reported that work had not affected their

physical health.

Eleven clients, irrespective of service, continued seeing

their psychiatrists with the same frequency as before they

started working, while seven said they were seeing their

psychiatrists less often. Four IPS and eight Vocational

Service clients reported medication side-effects. Six clients,

however, stated that their side-effects decreased while they

were working. Work was also found to reduce feelings of

boredom (n = 10).

Negative factors

There were also several negative consequences of working.

Half of the working clients in the Vocational Service, and a

few IPS working clients, stated that one of the most

important negative consequences of work was the

increased levels of stress, tiredness and lack of stamina. As

one client explained, ‘too much work is stressful’. This was

complemented by the quantitative data, which showed that

although most clients reported increased energy levels after

they started working, some Vocational Service clients

reported that their energy levels decreased. The increased

levels of stress experienced by clients were due to the

nature of their jobs but also to conflicts with colleagues.

Both groups who had worked stated that having conflicts at

work (or fear of such conflicts) was one of the important

negative aspects of work: ‘You have to cope with more

stress and pressure, as there could be difficulties in getting

along with team members’; ‘There is a risk of being bullied

at work’.

Clients also felt work provided them with more structure

in their lives but less control: ‘There is unwanted structure

in your life. You have to work at certain times; there is a

lack of flexibility and more obligations’. Work was asso-

ciated with ‘interfering with one’s free time’ and with

imposing ‘a more structured life’, as one client explained:

‘It is sometimes not easy to get up early in the morning.

You are less flexible when working, due to the fixed

structure that you need to follow’. Another client added:

‘Work makes demands on you and when one works there is

less time for oneself’.

Disclosure of mental health problem

Clients were equally divided between those who had dis-

closed their mental illness at work and those who had not.

Of those who did, almost all had had positive feedback

from their colleagues and employers. One client stated:

‘They responded well, they always encouraged me posi-

tively’, while another said: ‘They knew it from the

beginning and they had a positive attitude’. Clients felt that

their employers reacted positively and did not discriminate

against them: ‘There was no special reaction. They treated

me like a normal person’. In some cases, the employer

Soc Psychiat Epidemiol (2009) 44:961–970 967

123

asked for more information about the illness or the medi-

cation: ‘They did not know much about psychiatric illness,

but when I told them they reacted with sympathy, accep-

tance and benevolence’. One client, however, received a

negative response and was labeled ‘disabled’. There was

little evidence of contrasts between the IPS and Vocational

services in the way they handled disclosure and possible

stigma. Some IPS clients, however, reported being sup-

ported when they chose to disclose: ‘My IPS worker spoke

to my employer and gave information about my illness, the

abilities I have. My IPS worker was often at my workplace

and initiated dialogues between me and my employer’.

Clients who chose not to disclose their mental illness

made this decision mainly out of a fear of stigma and

discrimination: ‘I did not say that I suffer from a mental

illness, as I did not want to be perceived as a person with a

psychiatric illness due to stigma’. They also reported a fear

of social disapproval: ‘I feel embarrassed for having a

psychiatric illness and having to be looked after; people

make me feel guilty for receiving disability benefits’.

Discussion

In this qualitative study, 48 clients with a history of psy-

chosis from six different countries described their

experiences of trying to find and keep a job with the sup-

port of an IPS worker or regular vocational worker. It thus

provides a detailed picture of the experiences of this pur-

posive sample, to complement the broader picture provided

by the study’s primary findings. IPS was found to double

clients’ access to work, while those in the Vocational

Service were significantly more likely to drop out of the

service and to be rehospitalised [8]. Working, regardless of

which service the client was seen by, was associated with

better clinical and social functioning and a slight decrease

in depression [9].

In this paper, the first to our knowledge to interview in-

depth the clients of a comparison (vocational services) as

well a supported employment group, we have focused on

the differences between the two services and between cli-

ents who found work and those who did not. No special

attention has been given to differences between countries,

due to the small number of clients interviewed at each

centre. This means that the impact of local context could

not be addressed in this paper, although it is known to have

had an impact on the primary quantitative findings of the

study, which showed that local unemployment rates

explained a significant amount of the heterogeneity in IPS

effectiveness, while national economic growth and welfare

systems influenced overall employment rates [8].

The insights of this study are also limited to people with

psychotic illnesses. Whether they would generalise to

people with other mental health problems would be a

matter for future research. Some of the factors cited by

clients in this study may also be relevant to others seeking

work in a depressed job market, although factors such as

stigma and symptoms are clearly specific to those with

mental health problems. While the sampling for the study

was purposive, it is possible that in inviting appropriate

clients for in-depth interview, researchers may inadver-

tently have chosen those more amenable to contact with

services, causing a degree of selection bias. Both positive

and negative appraisals of services and the experience of

working were reported by the sample, however.

Clients across the board reported barriers to finding

work consistent with previous studies, such as psychiatric

symptoms and stigma [3, 25]. Although clients from the

two different services reported similar problems, not sur-

prisingly it was the group who had received the Vocational

Services and had not obtained work who reported the most

barriers. Differences in the kinds of help reported reflected

differences between the two service models. The type of

support that the IPS Worker offered to clients clearly

ranged from increasing clients’ motivation to write an

application letter to actually finding a job for the client,

although most clients regarded the IPS Worker as having

found the job for them. IPS clients also reported slightly

more help in maintaining employment. By contrast,

Vocational Service clients received more help in finding

sheltered employment, training or placement. The greater

likelihood of Vocational Service clients feeling they had

not received much help from the Vocational Worker may

also have indicated that they related to the Vocational

Service as a whole (whereas by contrast the IPS service

comprised a single individual worker), although named

workers were provided for all Vocational Service clients.

Nevertheless, some clients from each service felt that

they had not had sufficient help. Vocational Service clients

felt that they had lacked general help and support in

looking for jobs, as well as a more individualised approach

tailored to their particular needs. Some IPS clients felt that

they had wanted their IPS Worker to have more knowledge

of their chosen field of work or benefits and had also

wanted more frequent contact and support while at work, a

stated component of the IPS model [1] which has been

found helpful in other qualitative studies [3] and advocated

as a feature of the approach needing increased emphasis

[11].

The importance of help maintaining jobs for people with

severe mental illness has been attested to by Becker and

colleagues [2], who found that a large proportion of jobs

ended unsatisfactorily. They emphasised the need for help

with social interactions at work and with managing psy-

chiatric problems while working. Although clients from

both services reported difficulties with this, IPS clients

968 Soc Psychiat Epidemiol (2009) 44:961–970

123

were actually more successful at keeping their jobs [8]. Job

preferences were more often taken into account in the IPS

services, which is consistent with the IPS model. This has

been found to be helpful in ensuring greater job tenure

[19]. Nevertheless, even some IPS clients reported their

initial preferences not to be closely matched to the actual

jobs they obtained.

Clients expressed similar views about the impact of

work, which they associated with financial stability,

improvement of social life, increased self-esteem, inte-

gration into society and amelioration of their symptoms,

supporting the primary findings of our study [9] as well as

those of Strickler and colleagues [25]. They also reported

reduced feelings of boredom and isolation. Moreover, work

helped clients increase their self-esteem, supporting pre-

vious findings that work served as a means to build self-

efficacy and gave clients as sense of self-empowerment

[17, 25]. Our finding that work also served as means to

improve clients’ social lives and integration into society

were consistent with those of Boardman and colleagues [4].

Most clients who disclosed their mental illness at work did

not experience a negative reaction, consistent with an earlier

study [13]. They also reported negative consequences,

however, citing increased levels of stress due to conflicts

with work colleagues, lack of control, more structure and

less free time, as also found in previous studies [2].

Findings from these in-depth interviews reflect a dif-

ference in service models that has also been tested

quantitatively, with the difference in fidelity between IPS

and Vocational services being a predictor of IPS effec-

tiveness at each international centre [10]. Most clearly, IPS

clients reported a higher level of support in searching for

work and a greater likelihood that their preferences would

be taken into account. More surprisingly, IPS clients along

with Vocational Service ones reported not receiving as

much follow-up support as they would have like. Accord-

ing to the qualitative reports of these clients, the success of

IPS, which doubled the access to work of this difficult

group as well as their job tenure, seems to have been

achieved without recourse to this key feature of the model,

even though overall levels of IPS fidelity were high [8].

Further work in disaggregating the IPS model and assess-

ing the impact of each component would clearly be

valuable.

Acknowledgments This study was funded by a grant from the

European Union, Quality of Life and Management of Living

Resources Programme (QLRT 2001-00683). Thanks are due to Greg

McHugo for methodological advice, to Deborah R. Becker and Miles

Rinaldi for training the IPS Workers, and to the IPS Workers them-

selves: Alison Lewis (London), Wulf Dorn and Eva Marischka (Ulm),

Donato Piegari (Rimini), Bettina Bartsch and Patric Meyer (Zurich),

Anne Mieke Epema, Laureen Jansen and Bea Hummel (Groningen)

and Petar Karaginev (Sofia).

Conflict of interest statement We declare that we have no conflict

of interest.

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